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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804073
Report Date: 05/19/2022
Date Signed: 05/19/2022 07:09:40 PM


Document Has Been Signed on 05/19/2022 07:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SUMMER ROSE SENIOR LIVING LLCFACILITY NUMBER:
486804073
ADMINISTRATOR:FROELICH, RICHARDFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(707) 515-9099
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 2DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:59 PM
MET WITH:Richard Froelich, Licensee/AdministratorTIME COMPLETED:
07:15 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a second pre-licensing inspection and met with Licensee & Administrator Richard Froelich and Gainel Malybaerva. Fire clearance has been approved for 6 non-ambulatory residents by the Vallejo Fire Department on 4/28/2022. There is a total of 2 residents living in the home.

Facility is a one floor facility which includes kitchen, laundry room, living room area, bathrooms, office area, dining room, 3 resident's bedrooms, 1 staff bedroom and 3 bathrooms. LPA toured the facility on 5/19/2022 with Gainel Malybaerva. Home was found to be at a comfortable temperature with all exits free from obstruction.
A previous pre-licensing inspection was conducted yesterday 5/18/2022 and there were several items that required corrections. During today's visit, LPA observed the pantry area has been updated and canned goods are labeled with expiration dates, LPA did not observe expired food. There was a sufficient supply of both perishable and nonperishable foods and food was stored properly as required by Title 22 Regulations. Hot water temperature measured 101 degrees F and facility has been adjusting the water heater to ensure it is within Title 22 acceptable regulation of 105 to 120 degrees F. Applicant will continue to maintain a 7 day log to ensure acceptable water temperature. Applicant purchased and installed new hard wired smoke detectors that were tested during the inspection and found to be operating properly. Mitigation Plan was approved during inspection.

The following corrections will need to be submitted prior to licensure: Proof of water temperature between 105-120 degrees F. and proof of auditory alarms in all exit doors and evidence of liability insurance.

Component III Orientation was completed with Applicant/Administrator Richard Froelich.

No citations issued.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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